American Journal of Nursing Research, 2018, Vol. 6, No.

4, 198-207
Available online at http://pubs.sciepub.com/ajnr/6/4/8
©Science and Education Publishing
DOI:10.12691/ajnr-6-4-8

Effect of Educational Training Intervention on

Overcoming Nurses' Barriers to Screening Intimate
Partner Violence against Women in Outpatient Clinics
Mervat Mostafa Arrab*, Hanady Shabaan Ibrahim

Family and Community Health Nursing, Faculty of Nursing, Menoufia University, Egypt
*Corresponding author: ibr4ever73000@hotmail.com

Abstract Intimate partner violence (IPV) against women is an important public health problem facing women
globally. Many barriers facing nurses and other healthcare providers to screen abused women were reported in many
studies. Aim: The aim of the current study had twofold; First, to examine barriers to intimate partner violence
screening among nurses in outpatient clinics. Second, to evaluate the effect of an educational training intervention
on nurses for barriers to intimate partner violence screening. Study design: A Quasi-experimental study was used.
Setting: The study was conducted in outpatient clinics at two hospitals (University Hospital and Education Hospital
in Shebin El-Kom City. Menoufia Governorate, Egypt). Subjects: Seventy-five nurses who completed the
educational training intervention were included according to power analysis estimation. Tools: Self-administered
questionnaire to examine the barriers for IPV screening among nurses which consisted of two parts: part 1:
demographic data of studied nurses and part 2: The Domestic Violence Health Care Provider Survey instrument to
investigate the barriers to IPV screening among nurses. Results: Nurses reported several sources of barriers based
on the DVHCPS instrument items including self-efficacy, system support, victim blaming, professional role
resistance, and victim provider safety. There was a highly statistically significant difference regarding barriers to
IPV screening (P<0.001) and screening examination rate was increased by nurses (P<0.001) after the
implementation of the educational training intervention. Conclusion: This study highlights the beneficial effect of
the educational training intervention as an effective method in reducing the barriers for IPV screening among nurses
for women attending the outpatient clinics; improving the rate of screening and periodical examination of nurses
regarding IPV. Recommendation: In-service training courses for nurses on current updates regarding intimate
partner violence screening examination technique, regular training for nurses about intimate partner violence
screening tool in-addition, IPV protocol management for abused women attending outpatient clinics.
Keywords: intimate partner violence, screening, barriers, educational training intervention
Cite This Article: Mervat Mostafa Arrab, and Hanady Shabaan Ibrahim, “Effect of Educational Training
Intervention on Overcoming Nurses' Barriers to Screening Intimate Partner Violence against Women in Outpatient
Clinics.” American Journal of Nursing Research, vol. 6, no. 4 (2018): 198-207. doi: 10.12691/ajnr-6-4-8.

Healthcare providers including nurses are the

1. Introduction
Intimate partner violence (IPV) is "any behavior within
an intimate relationship that causes physical, sexual, or
psychological harm" [1]. It represents a major public
threat to the health and rights of women worldwide. In a
multi-country study conducted by WHO [2] revealed that,
one third of all women have experienced physical
and/or sexual violence by an intimate partner" [3], in
addition to, it is estimated that 5.3 million incidences of
IPV victimizations of women occur each year [4].
Intimate partner violence has physical, social and
mental health consequences for short- and long-term [5].
Women who had experience of IPV use health services
clinics more often than women with no experience of IPV
[6] these visits are considered an opportunity for
healthcare providers to determine women's experiences of
IPV and reduce negative health consequences [7].
foundation stone in preventing IPV, identifying abused
women early, providing necessary treatment, and referral
to appropriate resources. However, nurses are in the
critical position to interact, detect and reply to IPV victims
[8]. Lack of knowledge, heavy workload, language barriers,
threats to personal safety, the healthcare hierarchy,
and lack of communication and collaboration between
various stakeholder groups within the healthcare
system are important barriers facing providing care [9].
Nurse's barriers are lack of appropriate services and
support within hospitals and in the society. Barriers
to routine screening for IPV are; time constraints,
lack of protocols and policies, and departmental
philosophies of care that may conflict with IPV screening
recommendations [10]. So, nurses' educational and
training needs response will help them function
autonomously within multidisciplinary teams when caring
for abused women considered an urgent need for the
health care system [11].
 American Journal of Nursing Research
The most common women's responses to IPV are
crying, hit back, hide, seek immediate safety by going to
their mothers' houses, thinking of suicide, or few informed
the police [12]. Emergency and primary health care
settings are most important settings for identifying and
help IPV victims. Healthcare settings should be equipped
to manage the crisis, emotional support, information,
guidance, private communication with a healthcare
provider and to make connections to community-based
social service agencies [13].
1.1. Significance of the Study
Violence is a worldwide event. In all societies, it is a
fact of life and across all cultures, regardless of
socio-economic status. In a developed country like
America, women are six times more likely to be violated
by intimate partners than men [14]. In Egypt, screening
for IPV has the potential to improve health outcomes for
women and their families, promote early detection,
prompt interventions and reduction of the adverse effects
of IPV [15]. Despite the importance of routine screening
of IPV for all women in health care settings, it is still low
as reported [16]. In Egypt 26% of married women get
violated physically and/or sexually by IPV [17]. Intimate
partner violence violates the basic women rights which
results in serious injury or death [18]. For detection,
reporting, and referring the IPV cases to the appropriate
facilities nurses were in a vital situation this is with the
determination of the rate of IPV among women. Different
barriers facing nurses for screening include lack of
information, training, protocols, and administrative
support and referral and community recourses about IPV
[19]. Increase detection of cases and screening rates of
IPV may reduce barriers and lead to earlier referral of IPV
victims. Less than 2% of women were screened about IPV
by health care providers [20], and through regular
screening and education by clinicians can detect the
violence before it becomes late. Health care professionals
have a unique opportunity to stop the cycle of abuse by
intervening, promoting safety, and preventing the death of
IPV victims [21]
Major barriers to assessing and intervening in suspected
cases of intimate partner violence continue to exist
within the healthcare system mainly due to lack of
education, reflecting that assessment of domestic violence
is proportionate with educational offerings [22]. The
American Nurses Association [23] advocates for the
education of registered professional nurses in the
assessment, prevention, intervention and referral skills
related to domestic violence. The first-line response for
people who experience domestic violence is healthcare
professionals. It is vital to have education, policies, and
protocols in place so that they can identify, record IPV
and assist victims with getting the services and support
their need. Unfortunately, healthcare professionals face
personal barriers, job-related barriers and patient-related
barriers that may hinder their ability to effectively
identifying and assisting victims of intimate partner
violence. In addition, the dynamics of IPV are complex,
and it is often difficult to understand how it presents
within affected women [24].
199
1.2. Aim of the study
The purpose of the current study was to assess the
nurses' barriers to screen women to intimate partner
violence in outpatient clinics and to evaluate the effect of
an educational training intervention on nurses' barriers to
IPV screening.
1.3. Research Hypotheses
1- Nurses’ barriers to IPV screening of abused women
will have higher percentage after receive educational
training intervention compared to before the educational
intervention.
2- The nurses' screening practice towards IPV during
providing their nursing services will be improved after
receiving the educational training intervention compared
to before educational intervention.
3- The examination rate for screening towards IPV will
be improved after receiving the educational training
intervention compared to before educational intervention.
2. Subjects and Methods
2.1. Research Design
A quasi-experimental design with pre and post test of
educational training intervention was used.
2.2. Research Setting
This study was conducted at outpatient's clinics
in two governmental hospitals (University Hospital and
Education Hospital in Shebin El-Kom City, Menofia
Governorate, Egypt).
2.3. Research Sample
A study population comprised all nurses working at
antenatal care, family planning, obstetric units and
forensic medicine department in the previous settings,
(n=125 nurses). Inclusion criteria: Nurses who were
accepted to participate in the training program and not
participated in other studies with similar objectives,
Egyptian, diploma nurse, bachelors and postgraduates.
2.3.1. Sample size determination
n = Z2 pq/ E2 = 400
Z at 95% confidence = 1.96
P: estimated percent in population = 50%
q: 100-p= 100-50= 50%
e: accepted sample errors (0.05)
Power = 0.8
n= 384.
Since the population size less than 10000, the final
sample estimate (nf) calculated using the formula:
nf = n/1+(n/N)
Where: nf= The desired sample size (when population is
less than 10000)
n= the desired sample size (when population is more than
10000)
200 American Journal of Nursing Research
N= the population of nurses in the selecting setting is 125
Nf = 384/1+ (384/125) = 93 participants.
From a total of 93 nurses, 18 participants were excluded
from the study due to lack of participation in the sessions,
not completing the questionnaire, or taken sick leave
while 75 nurse are actually participated in the study and
complete the intervention.
2.3.2. Sampling Procedure
A stratified random sampling was utilized, including 75
nurses as participants from the study population out of 125
nurses. The study population was divided into the
following strata’s: pediatric units, antenatal care units and
family planning, obstetric units and forensic medicine
department strata in the previous setting. The number
of the participants selected from each stratum was
equally proportioned to the population of the strata.
The researcher obtained a list of all eligible nurses’
participants from each stratum and then randomly picked
the participants from each stratum to obtain the desired
sample (75). The random selection from each stratum was
achieved by assessing a numerical value to each
participant in each stratum and then a randomizer
computer package was used to generate the desired sample
size from all the strata.
2.4. Tool of the Study
Tool: Self-administered questionnaire to assess the
barriers to IPV screening by nurses which consisting of
two parts:
2.4.1. Part (1) demographic data (age, sex, job,
religious, educational level, marital status, years of
experience, and health setting/units where they work).
2.4.2. part (2) the Domestic Violence Health Care
Provider Survey (DVHCPS): Instrument was used to
investigate the barriers for IPV screening by nurses
(measure health care providers’ IPV knowledge, attitudes,
beliefs, and the ability to apply this knowledge in daily
practice and IPV screening. instrument was developed by
the Group Health Cooperative and Harborview Injury
Prevention and Research Center, (1997) [25].
Scoring system of the Domestic Violence Health Care
Provider Survey (DVHCPS):
The Domestic Violence Health Care Provider Survey
(DVHCPS) is Arabic translated valid tool which was
adopted for this study. The DVHCPS includes 35 items
with a 5 point Likert scale ranging from Strongly Disagree
(0) to Strongly Agree (4). Survey items are categorized
into six domains. These domains include self Efficacy
(7 items), social support (4 items), victim blaming (7
items), Professional role resistance (7 items), victims’
providers’ safety (10 items).
The questionnaire was evaluated giving a score of 0 –
140.The total score of each nurse was categorized
arbitrarily into “poor management” when the nurse
achieved less than or equal ≤ 50% of the total score, and
“good management” when the nurse achieved > 50% of
the total score. Accordingly, if the total “DVHCPS” score
of a nurse was “0 - 70”, she/he was classified as has poor
management towards IPV, and if the total DVHCPS”
score of a nurse was “71 – 140”, she was classified as had
“good management towards IPV”.
Concerning nurses’ IPV screening, we studied it in a
list of 7 items, each was five points Liker scale (0 – 4) as
(0) for “Do not exam.”, (1) for “Examine 1-20%”, (2) for
“Examine 21-40%”, (3) for Examine 41-60% and (4) for
Examine > 60%.
2.5. Study Procedure
The study was conducted according to the following
steps:
(1) Before conducting the research, the researchers
followed the ethical issues and official permission
was obtained from the ethical committee, faculty
of nursing, Menoufia University
(2) An official letter from the Faculty of Nursing,
Menofia University was forward to the manger of
each hospital (University Hospital and Education
Hospital in Shebin El-Kom City, Menoufia
Governorate, Egypt) to take permission to conduct
the study after explaining its purpose and importance.
(3) Informed written consent was obtained from
nurses before starting the data collection. The
agreements were taken after the aim of the study
was explained and informed about what would be
done with the results. They were given an
opportunity to refuse or withdraw at any stage of
the study and were assured that the information
would remain confidential and used for the
research purpose only.
(4) Letters were sent to key system decision makers
and securing system in each hospital and
community partners such as national council for
women rights and human rights and civil
institution to be represented in the study.
(5) Tool of the Domestic Violence Health Care
Provider Survey (DVHCPS). It contains 42 items
with a 5 point Likert scale ranging from s strongly
disagrees to strongly agree. it includes six domains
(self-efficacy which contain 7 items, system and
institutional barriers contain 4 items, victim
blaming contain 7 items, professional role
resistance 7 items, victims’ providers’ safety
contain 10 items, and frequency of IPV Screening
contain 7 items).
(6) Validity of the tools: It was determined by a jury
of experts in community medicine and community
health nursing, obstetric and psychiatric health
nursing specialty, and then modifications were
carried out according to the expert's judgment on
the clarity of the sentences and convenience of the
contents.
(7) Reliability of the tools: The researcher carried out
the reliability of the instrument with an overall
Cronbach alpha, it was found to be acceptable and
ranging from 0.73 to 0.91. This indicates that the
instruments were consistent and reliable in
achieving the purpose of the study.
(8) A pilot study was carried out on 10 nurses to
assess the clarity, feasibility, applicability of the
study tools, and the time needed to fill each tool.
The sample of the pilot study was excluded from
the total sample to assure the stability of the
results. The time spent to fill the tools from
 American Journal of Nursing Research
participants ranged between 30 to 45 minutes
according to the needed explanation.
(9) The 75 nurses who complete the questionnaire
divided into two group according to their place,
they received the educational training nursing
intervention. The educational nursing intervention
was implemented during five months, the field
work started in January 2017 till June 2017.
(10) Implementation of the study passed into three
phases (assessment phase, implementation phase
and evaluation phase).
2.5.1. Assessment phase: Data was collected in a
comfortable and private place was chosen for the
interview. Orientation was done about the purpose of the
study, significance, content. Also, researchers informed
nurses by another's persons who will be included in the
sessions.
2.5.2 Implementation phase: The researcher arranged
the intervention sessions based on prevention strategies
consistent with The Minnesota Department of health,
(2001) [26] it has published public health strategies
to address societal issues, which conceptualizes
population public health interventions to be carried out on
three different levels: Individual-based strategies this
concerned with nurse’ role in screening for violence
among women attending outpatient clinics, systems based
strategies which concerned with working collaboratively
within healthcare team and Community based strategies
concerned with working with community institutions and
organizations. This educational nursing intervention was
developed and given through sessions’ each session has a
general objective and set of specific objectives. The
researchers divided the study group into 2 groups'
according to place of work each group consisted of 30-35
nurses. The educational nursing intervention used has
been sequenced through the three educational sessions;
session started according to nurses’ suitable time, usually
at 9 Am, three days per week at the morning shift, the
duration of each session was ranged from 60-90 minutes
including periods of discussion according to participants'
achievement, progress and feedback in groups. A coffee
break was available for the participants. The study
intervention's sessions carried out in a comfortable
seminar room equipped with suitable materials. Methods
of teaching include lectures, question and answer, and
role-playing, and techniques such as brainstorming, group
discussion, and Power-Point presentation included
educational videos and true stories of case studies by
using data show. Also, nurses were given an illustrated
guide booklet about IPV; this illustrated booklet was
developed by the researchers after reviewing the
related literature. At the beginning of the first session
of the nursing intervention, the telephone number
of the researchers and participants were available to each
other. Nurses were oriented regarding the contents of
educational nursing intervention, its purpose and its
impact; and were informed about the time of the next
session. Each session started by a summary about what
has been discussed in the previous session and the
objectives of the new session. The session ended
by a summary of its contents and feedback from the
participants.
201
Educational nursing intervention:
First session (Nurse -focused- approaches): this
session aimed to enhance nurse's awareness of IPV issue
and acquire nurses about screening tools and routine
screening for identification of abuse. This was done
through acquiring knowledge for nurses to identify the
following items background and history of IPV, related
definitions, prevalence of IPV in Egypt compared to
other countries, its risk factors, characteristics of abused
women, the consequences of intimate partner violence
on women and their families, dynamic to break the
cycle of violence in domestic abused women, encourage
victimized woman to report to IPV to legal entities,
training them on how to ask about and screen violence in
safe work environment without the risk of ostracism and
use therapeutic approaches probability and knowledge of
and collaboration with local advocacy programs; legal and
ethical issues in working with IPV survivors skills training
for asking about and responding to reports of IPV from
patients, including assessing danger; and helping to
develop safety plans.
The second session (System-based approaches): this
session aimed to develop of the clinic or unit-based
policies and procedures, which are critical to a successful
systems-based response to IPV. Through join healthcare
system which included healthcare administrators and
managers, hospital communication system, social and
psychological specialists, security system of outpatients
clinics in hospitals which included: provide education
about IPV issue, increase staff awareness about how IPV
affects health and increases sensitivity to the needs of
patients in crisis, prompt intervention to help victims, time
management, collaboration, enforce screening protocols to
manage the IPV event collaboratively as one team.
Third session: (Community-based approaches): this
session aimed to collaborate with local advocacy agencies
and IPV experts. Through guide healthcare community
leaders and community resources about the importance
of Legislations related to IPV issue, Documentation,
Reporting, and make appropriate referrals, Advocacy,
establish network with domestic violence advocacy
programs and civil institutions which include women
rights’ and human rights’ and drawing up protocols for the
proper management of abuse.
2.5.3. Evaluation phase: after implementation of the 3
educational training intervention sessions for nurses, the
researcher interviewed the nurses 3 months later from the
beginning of the educational intervention to evaluate the
post evaluation data.
2.6. Statistical Analysis
- Data was coded and transformed into specially
designed form to be suitable for computer entry process.
Data was entered and analyzed by using SPSS (Statistical
Package for Social Science) statistical package version 22.
Graphics were done using Excel program.
- Qualitative data as age were presented by mean (x) and
standard deviation (SD). Qualitative data were presented
in the form of frequency distribution tables, number and
percentage. It was analyzed by chi-square (x2) test.
However, if an expected value of any cell in the table was
202 American Journal of Nursing Research

less than 5, Fisher Exact test was used (if the table was 4
cells), or likelihood Ratio (LR) test (if the table was more
than 4 cells). Level of significance was set as P value
<0.005 for all significant tests.
3. Results
Table 1 illustrates that a total of 75 Egyptian nurses,
primarily female (n=61, 8.3%) sample participated in this
study. The mean age of participants ranged from 36-55
years' old which represented 66.7% of the total sample.
The most frequent years of nursing experience was ranged
from 10-20 years old (41participant which represented
54.7%). Most nurses were married (n=56, 74.7%) with the
remaining nurses being single (n=12, 16%) or divorced
(n=3. 4%). The total sample of the nurses was 75 divided
into 19 nurses was taken from pediatric units, 22 nurses
from antenatal and family planning outpatient from both
hospitals, 15 nurses form obstetric units from both
hospitals and 19 nurses from the forensic department in
the university hospital.
Table 2 Nurses reported several sources of barriers
based on the DVHCPS instrument items including
self-efficacy, system support, victim blaming, professional
role resistance, victim provider safety. Related to
self-efficacy and nurse's capability for screening, about
98.7% of nurses disagreed that they have access to IPV
strategies to help victims change IPV situation and 96%
disagreed that they were there are strategies to help
batterers and have access to IPV information and 48% feel
confident for referring batterers.

Table 1. Socio-demographic characteristics of the nurses (N=75).

Socio demographic data Frequency Percent
25 ≥35 years 25 33.3
Age groups 35 -55 years 50 66.7
Mean ± SD 38.01±6.06
Male 14 18.7
Sex
Female 61 81.3
Diploma 67 89.3
Job
Observer 8 10.7
Diploma 65 86.7
Educational level Bachelors 8 10.7
|Master degree 2 2.7
< 10 years 17 22.7
10 - 20 years 41 54.7
Experience groups
21 - 35 years 17 22.7
Mean ± SD 16.31±6.21
Pediatric outpatients 19 25.3
Antenatal care and family planning outpatients 22 29.3
location of job Obstetric outpatients 15 20.0
Forensic department outpatients 19 25.3
total 75 100
Married 56 74.7
Single 12 16.0
Social status
Widowed 4 5.3
Divorced 3 4.0
Total 75 100.0

Table 2. Barriers for screening Intimate partner violence women identified by nurses (N=75)
Percent
Screening Barriers Disagree Agree Total
1. Self- efficacy No % No %
1. Have no time to screen 48 49.3 27 50.7 100.0
2. There are strategies to help batterers 73 96 2 4 100.0
3. Strategies to help victims change IPV situation 74 98.7 1 1.3 100.0
4. Feel confident for referring batterers 36 48 39 52 100.0
5. Feel confident to refer victim 30 40 45 60 100.0
6. Have access to IPV information 72 96 3 4 100.0
7. Know ways to ask victims to decrease IPV victims risk 63 84 12 16 100.0
2. Social support
1. Access to social workers to assist IPV victims 71 94.6 4 5.4 100.0
2. Social workers can help victims 73 97.3 2 2.7 100.0
3. Access to mental health referral 72 96 3 4 100.0
4. Mental health services can help victims 61 81.3 14 18.7 100.0
 American Journal of Nursing Research 203

Percent
Screening Barriers Disagree Agree Total
3. Victim blaming
1. Victim get something from IPV relationship 52 69.3 23 20.7 100.0
2. choose to be IPV victims 48 64 11 36 100.0
3. Victims and batterers are responsible for IPV 12 16 63 84 100.0
4. Patient personalities makes them IPV victims 9 12 66 88 100.0
5. Women go against traditional roles lead to IPV 25 33.3 50 66.7 100.0
6. Victim passive personality lead to IPV 18 24 57 76 100
7. action leads to IPV 45 60 30 40 100
4. Professional role resistance
1. Afraid of offending patient when asking about IPV 20 29.4 55 73.3 100.0
2. Asking about IPV is invasion to patient privacy 22 29.3 53 70.7 100.0
3. It is demeaning to ask about IPV 23 30.7 52 69.3 100.0
4. Asking non-abused patients makes them angry 13 17.3 62 82.7 100.0
5. It is non- nursing role to resolve couple conflict 23 30.7 52 69.3 100.0
6. Investigation causes of IPV is non-medical role 34 42.6 41 57.4 100.0
7. If patient not disclose, they feel it is not my business 18 24 57 76 100.0
5. Victim provider safety
1. Reluctant to ask batterers for my personal safety 6 8 69 92 100
2. Workplace security is not enough to deal with IPV 2 2.7 73 97.3 100
3. Afraid of offending patient when asking about abusive behavior 2 2.7 73 97.3 100
4. Challenging batterers direct their anger to care providers 2 2.7 73 97.3 100
5. There are ways to ask about IPV without endanger nurse 15 20 60 80 100
6. Nurses can effectively discuss IPV with batterers 25 33.3 50 66.7 100
7. Can discuss IPV with batterers without endanger victims 36 48 39 52 100
8. Avoid dealing with batterers for victims safety 3 4 72 96 100
9. No ways to ask batterers without endanger victims 39 52 36 48 100
Afraid when dealing with batterers increase victims risk 25 33.7 50 66.3 100

For the system support domain, most 97.3% disagreed Related to victim/ provider safety domain, nurses were
that social workers can help IPV victims, and 96% concerned about their own safety and victims’ safety.
disagreed that there is access to mental health referral, However, approximately all nurses (97.3%) reported that
94.6% disagreed that social workers to assist IPV victims. workplace security is not enough to deal with IPV, afraid
Moreover, 81.3% believe that IPV victims do not have of offending patient when asking about abusive behavior
access to mental health services. and challenging batterers direct their anger to care
Related to victim blaming domain, 69.3% of nurses providers. However, about eighty percent of nurses agreed
believed that victims’ personality gets something from that it was possible to ask about IPV without endangering
IPV relationship. In addition, 64 % agreed that people themselves. Despite this, 66.3% nurses were afraid when
choose to be IPV victims. dealing with batterers increase victims’ risk.
According to professional role domain, 73.3% of nurses This Table 3 reveals that there was high statistical
agreed that they are afraid of offending patient when significant improvement after the educational training
asking about IPV and 70.7% agreed that asking about IPV intervention for nurse's response to barriers of IPV screening
is invasion of patient privacy and over half (57.4%) agreed which represented in five domains (self-efficacy, system
that it was not their role to ask about IPV when victims and institutional barriers, victim blaming, professional
choose not to disclose their victimization. role resistance, victims’ providers’ safety).
Table 3. Pre and post intervention about nurses’ responses to barriers of IPV screening that they may face during providing their health care
services (N=75)
Pre intervention Post intervention
Nurses Barriers’ for IPV screening Poor Good Poor Good Test of sig. P value
N0. (%) N0. (%) N0. (%) N0. (%)
Self-efficacy 63 (84%) 12 (16%) 0 0% 75 (100%) X2=128 0.000 HS
Social support 73 (97.3) 2 (2.7%) 7 (9.3%) 68 (90.7%) X2=243 0.000 HS
Victim blaming 37 (49.3%) 38 (50.7%) 0 0% 75 (100%) X2=140 0.000 HS
2
Professional role resistance 21 (28%) 54 (72%) 0 0% 75 (100%) X =153 0.000 HS
Provider safety 75 (100%) 0 ( 0%) 1 (1.3%) 74 (98.7%) X2=214 0.000 HS
204 American Journal of Nursing Research

Table 4. Effect of educational training intervention on nurses’ screening rate and periodical examination toward IPV during providing their
health care services*
Pre intervention P value
The examination rate of IPV
If yes, nurse’s screening
screening among nurses in the
last three months Screening rate Examin1-20% Examin 21- Examin 41-60% Examin >60% N0.
N0. (%) 40% N0. (%) N0. (%) (%)
Injuries (n=54) 14(25.9%) 10(71.4%) 4(28.6%) 0 0 0.000
Chronic pelvic pain(n=54) 5(17.9%) 3(60%) 2(40%) 0 0 0.000
Irritable-bowel syndrome(n=39) 9(23.1%) 6(60%) 3(40%) 0 0 0.000
Headache(n=53) 13(24.5) 8(61.5%) 5( 38.7%) 0 0 0.000
Depression-or Anxiety(n=31) 3(9.7%) 2(66.6%) 1(33.3%) 0 0 0.000
Hypertension/coronary artery
8(13.9%) 6(75%) 1(12.5%) 1(12.5%) 0.000
diseases(n=58)
patient is pregnant seek obstetric
7 (10.14%) 5(71.4%) 2(28.6%) 0 0 0.000
or gynecological care (n=69)
Post intervention P value
The examination rate of IPV
If yes, nurse’s screening
screening among nurses in the
last three months Screening rate Examin 1-20% Examin 21- Examin 41-60% Examin > 60%
N0. (%) 40% N0. (%) N0. (%) N0. (%)
Injuries (n=30) 12(40%) 0 2(20%) 8(60%) 2(20%) 0.000
Chronic pelvic pain(n=21) 15(35%) 0 5(33.3) 9(60%) 1(6.7%) 0.000
Irritable bowel syndrome(n=29) 15(34.5%) 0 9(60%) 4(26.7%) 2(13.3%) 0.000
Headache(n=20) 8(40%) 0 2(25%) 6(75%) 0 0.000
Depression or Anxiety(n=12) 4(33.3%) 0 0 4(100%) 0 0.000
Hypertension/ coronary artery
6 (25%) 0 0 3(50%) 3(50%) 0.000
diseases(n=24)
patient is pregnant seek obstetric
20(35.08%) 0 5(25%) 10(50%) 5(25%) 0.000
or gynecological care (n=57)

*Rows will not add to n=75, because not all nurses provided care to each type of patient.

Table 4 shows that there was high statistical significant
increase in nurses’ screening rate of IPV and also,
periodical examination during providing their nursing
services after the implementation of educational training
intervention was improved.
4. Discussion
Screening barriers are defined as those factors that
prevent nurses from screening women for potential IPV.
Barriers contributing to the low rate of IPV screening by
nurses can be categorized according to the DVHCPS into
five domains. The domains include self-efficacy, system
support, blaming the victims, professional role, and
victim/provider safety [27].
Regarding Self-efficacy barrier, approximately all study
nurses reported that they did not use strategies to help
victims and batterers. This high percentage might have
resulted from the lack of IPV knowledge provided to
nurses for IPV screening and intervention [28]. And about
half of nurses reported that they did not have enough time
in their daily practice for IPV screening. The same result
was obtained by [29] who studied Jordanian Nurses’
Barriers to Screening for Intimate Partner Violence who
reported that only about half of nurse using strategies to
help victims and batterers and 40% of study sample
reported that they did not have enough time for IPV
screening.
Regarding system support barrier was identified as the
greatest cluster of barriers among study nurses. System
support such as social and mental health services are
important so that victims can be referred to entities that
will provide help and support while promoting victim's
safety. Nearly all of the nurses disagreed with the
importance of social workers providing this much-needed
help and support, and only 2.7% of the nurses reported
that social workers were capable of providing the needed
help for IPV victims. In the same line [30] who studied
"system issues: Challenges to intimate partner violence
screening and intervention" reported that equally troubling
is that when nurse have access to social services, there
may still be gaps and an inadequacy in the services that
are provided to IPV victims. Nurses disagreed that mental
health services were important or capable to help IPV
victims. This might be a reflection that the nurses did not
have access to mental health services for their patients.
However, seeking mental health care is very important for
IPV victims. [31] studied determinants of depressive
symptoms in Jordanian working women stated that
Jordanian women who experienced IPV and depression
symptoms did not seek mental health services because
they were unaware of the serious impact that mental
illness can cause or the value of mental health care. In
addition, IPV victims have fears of being stigmatized by
their communities and families. Although, the importance
of seeking mental health services for eliminating or
decreasing psychological impacts of violence against
 American Journal of Nursing Research
women, Egyptian nurses undervalued this importance of
mental health services. Also, few health settings in Egypt
provide social and mental health services. So, even if
Egyptian nurses are educated about community services
available, nurses will likely be unable to access them.
More importantly, [32] studied the domestic violence
against women and its consequences on family health in
Maser El-Kadima district and reported that Egyptian IPV
victim’s refused to disclose IPV or to be referred to legal,
social, or mental services to avoid being culturally
stigmatized and for preserving the reputations of
themselves and their family
Regarding the victim barrier nurses held beliefs and
attitudes about IPV victims that likely hinder their screening
and take appropriate care. Nurses’ preconceptions and
beliefs included that victim had passive personalities that
resulted in the IPV situation. This finding are supported
by [29] and [33] who studied Health professionals’
perceptions of intimate partner violence against women in
Serbia" both of them indicate that victims of IPV are
sometimes perceived as having personalities that account
for their victimization: low self-esteem, self-blame, and
dependent personalities. Regardless a woman’s
personality, women should be blamed for the violence
they experience. This may have indicated that Egyptian
women live within Egypt’s cultural and religious rules.
Egyptian culture is conservative and believes in the
dominant role of the male over the female throughout the
lifespan. Women tend to stay in an IPV relationship for
the sake of their children, stigma of divorce, and economic
dependence on their husbands. Also, [34] studied spousal
violence in Egypt, population Reference Bureau reported
that Egyptian women will not be supported by their family
and culture and will experience resistance if they want
divorce.
Regarding professional barrier nurses have a professional
responsibility to appropriately screen all patients seeking
health care. Nurse held preconceptions about IPV screening
such as their inability to ask about IPV because it is a
sensitive familial issue and they fear offending patients or
making them angry, and feared to disrupt their patients’
privacy. According to professional role domain, the
majority of nurses agreed that they are afraid of offending
patient when asking about IPV and about seventy percent
agreed that asking about IPV is invasion to patient privacy
and over half nurses agreed that it was not their role to ask
about IPV when victims choose not to disclose their
victimization. These findings are supported by [29] and
[35] who studied domestic violence screening and treatment
in the workplace, whose participants indicated that IPV
screening was not a nursing role. Nurses should be
educated to screen and ask patients in an appropriate way
about IPV. Placing value on IPV screening is a necessary
first step towards the universal screening of all patients.
Regarding victim/ provider safety barrier. This study
indicated that nurses concerns and fears about their own
and victim's safety may be due to inadequacy of security
services at the Egyptian health settings to protect them
when interacting with batterers and screening victims for
IPV. This finding was similar to the findings [29] and [36]
they indicated that Jordanian victims underwent batterers’
retaliation and revenge and increased violence severity
and intensity after their IPV disclosure.
205
Regarding nurses screening for IPV, the findings
revealed that it was low. The highest screening rate was
done for women seen for injuries (25. 9%).the same
results were reported by [29] and [37] who studied care
provided in visits coded for intimate partner violence in a
national survey department, both of them indicated that
the most common diagnosis for IPV victims seeking care
in the emergency department in Jordan and Columbia was
related to upper and lower extremity injuries (52% and
49%, respectively). Also, [38] who studied domestic
violence management in Malaysia found that injuries
resulting from violence might be one of the most common
complaints seen at three primary health care clinics in
Malaysia. However, only half of the clinicians screened
and asked the patients about the underlying causes of their
injuries. A consistent lack of screening even for females
with injuries were occurring.
Determining the barriers for nurses to screen for IPV
can help planners and researchers reduce those barriers
[30]. Reducing barriers could increase screening rates for,
and detection of cases of IPV. Earlier detection can lead to
earlier referral for IPV victims [39]. Based on available
information, it was hypothesized that the frequency
of IPV screening after implementing educational training
intervention for nurses will help them in reducing the
barriers for screening and also increase the rate of
screening for IPV.
Results of the current study reported that there were
statistically significant differences before and after the
implementation of educational training intervention
regarding barriers of screening which can be clustered as
nurse attitudes, nurse beliefs, victim barriers, and health
institutions. On the same context, Johnson et al., [40]
studied evaluation of an IPV curriculum in a pediatric
hospital in USA by conducted a longitudinal study
incorporating pre and post participation assessment
questionnaire and showed that a 30-minute curriculum on
IPV screening was accompanied by a significant improvement
among nurses for IPV Screening (P<0.012), improved in
the nurses’ perceived self-efficacy (p <0.001), Also, [41]
studied the effect of an IPV educational program on the
attitudes of nurses in USA concluded that educational
programs led to an improvement in nurses’ attitudes. This
showed the positive effect of educational training
intervention in overcoming the barriers for IPV screening.
Similarly, [42] who studied increasing nurse's knowledge
and skills for enhanced response to IPV in USA through
investigated nurses’ needs about IPV and implemented an
educational program to enhance their practice. Phase 1 of
the study revealed the nurses' lack of knowledge regarding
community resources for IPV and their incompetence
related to the skills of IPV intervention. Phase II of their
quasi-experimental study showed that training programs
resulted in a significant improvement in nurses’ skills
(P<0.003). Also, [43] who studied training and documentation
improve emergency department assessment of domestic
violence victims in New Zealand indicted that training and
supervision for nurses were impotent to promote nursing
competence, enhance confidence, and increase awareness
when dealing with victims of IPV. Also, this study was
contradictory with the results of [44] who studied training
program for healthcare professionals in domestic violence
in England reported that most training programs are
206 American Journal of Nursing Research
limited in time frame (average one sessions of one –three
hours repeated or followed up, not mandatory and have
small numbers participating. The explanation or content or
design of program is often incomplete.
Regarding intimate partner violence screening rates are
variable and done infrequently before the implementation
of educational training intervention but there were highly
statistically significant increase screening rates of IPV
after the implementation of educational training intervention
due to certain factors which include its contents, screening
protocol implementation, providing a suitable environment
for disclosing sensitive information. This finding was
consistent with [45] studied a five-year follow-up study of
the Bristol pregnancy domestic violence program to
promote routine enquiry in United Kingdom likewise, [46]
studied training Sri Lankan public health midwives
on IPV both studies reported that there was positive
improvement in screening rates, increase in confidence
and skill level in practice and more positive attitudes towards
abused women were identified following implementation of
education programs for a new IPV screening or assessment
policy. Furthermore, [47] studied implementing successful
IPV screening programs in healthcare settings: Evidence
generated from a realist-informed systematic review in
Canada a systematic review of screening programs identified
that healthcare providers were more likely to screen for
IPV when they were confident with the process (usually
occurring with more extensive training programs). Similarity,
[48] studied intimate partner violence screening and
intervention in the healthcare setting in USA. Also, this
come in agreement with [47] and [49] studied domestic
violence screening in medical and mental health care
setting: overcoming barriers to screening, identifying, and
helping partner violence victims, this indicated that
overcoming barriers of domestic violence screening allow
nurses for improving the rate of screening in clinical
practice. In the same line, [50] studied screening and
intervention for intimate partner violence in healthcare
settings: creating sustainable system-level programs
reported and emphasized that a nursing educational
training program on IPV can increase nurses’ confidence
and competency in screening for IPV.
5. Conclusion
This study highlights the beneficial effect of educational
training intervention as an effective method in reducing
the barriers for IPV screening by nurses for women
attending the outpatient clinics; improving the rate of
screening and periodical examination of nurses regarding
IPV. This study highlights the importance of educational
training intervention as an effective strategy in reducing
the barriers in screening IPV by nurses in outpatient
clinics. A significant improvement in both screening and
routine examination rate to IPV are reported among nurses
after receiving an educational training intervention.
6. Recommendations
Based on the results of the present study, the following
recommendations were suggested:
• A common IPV screening tool and protocol of
management for abused women should be applied
in primary health care including outpatient clinics
and hospitals.
• In-service training courses for nurses on current
updates regarding IPV management.
• Join nurses, health care team and community
leaders in the management of IPV issue in
workplace and community settings.
• Further studies are needed with a large sample from
all governorates will provide a picture of IPV
screening, barriers, referrals and prevalence rate in
Egypt.
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